It’s extremely important that our resources go to those truly in need. While there’s no set formula for financial screening, we try to use common sense. In some situations, we will waive the financial need criteria; however, this decision must remain at our discretion.
Do You Qualify? To find out if you qualify, go to Passenger Qualifications.
Mission Request Form: Do you want to get started right away or is it after business hours? The Mission Request Form is available in two different formats and you can decide how you want to complete it and send it to us. First, decide if you want to print the form and complete it manually (choose the PDF version below), or complete the form digitally and save it on your computer (choose the Online version below). Then, decide how you want to send the completed form to us. You can send it to us by one of the following methods: 1) Mail it to us at Mercy Flight Southeast, 8864 Airport Blvd., Leesburg, FL 34748; 2) Fax it to us at (352) 326-9360; or 3) Email it to us at firstname.lastname@example.org
Mission Request Form (PDF) - This version can be downloaded and printed.
Mission Request Form (Online) - This version can be downloaded and completed on your PC if you have Microsoft Word (you will have to Enable Editing after this form opens if you are using Word 2010).
Medical Release Form: Patients must be able to be transported in an unpressurized small aircraft. After the patient has been qualified for our services and subsequently scheduled for a mission, we will fax a Medical Release Form to the patient’s physician who must complete, sign, and return the form to us prior to the scheduled mission.
The Medical Release Form is available below in two different formats if you need a copy for any reason.
Medical Release Form (PDF) – This version can be downloaded and printed. Then it should be completed and signed by the physician, and faxed back to us.
Medical Release Form (Online) – This version can be downloaded and completed on your PC if you have Microsoft Word (you will have to Enable Editing after this form opens if you are using Word 2010). Afterwards, the form should be printed and signed by the physician, and faxed back to us.
Do You NeedMore Information?
Patients, please ask your social worker or physician to call:
Mercy Flight Southeast Hotline (888) 744-8263.
In need of our services but you reside outside of Alabama, Georgia, Mississippi, or South Carolina? Please check the Air Charity Network™